A charge nurse is recommending postpartum clients for discharge following a local disaster. Which of the following clients should the nurse recommend for discharge first?
A client who had an emergency cesarean birth 1 day ago
A client who had a precipitous birth 36 hr ago and has a second-degree perineal laceration
A client who has preeclampsia and a blood pressure of 166/110 mm Hg
A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
The Correct Answer is B
A. A client 1 day post-cesarean birth is still at risk for postoperative complications (e.g., infection, bleeding, pain, immobility). This client requires ongoing hospital monitoring.
B. A client who delivered vaginally 36 hours ago and has only a second-degree laceration is generally stable and can safely be discharged home with proper instructions for perineal care.
C. The client with preeclampsia and severe hypertension (166/110 mm Hg) is at high risk for seizures, stroke, and organ complications. This client must remain hospitalized for stabilization and management.
D. A client recently transfused after postpartum hemorrhage needs continued monitoring for recurrent bleeding and transfusion reactions. Discharging this client would be unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client with a femur fracture and pain level of 7: Although painful, it is not immediately life-threatening compared to a myocardial infarction.
B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG: ST-segment elevation indicates acute myocardial infarction (STEMI). This is a medical emergency requiring immediate interventions to restore coronary perfusion (e.g., oxygen, nitrates, antiplatelets, possible PCI).
C. A client with C. difficile and fever: This infection requires isolation and treatment but does not pose an immediate threat to life.
D. A client with heart failure and 2+ edema: This is a chronic condition and can safely wait for assessment after the emergent cardiac case.
Correct Answer is ["A","B","C","D","E"]
Explanation
Rationale:
A. Heart rate decreased from 110/min on day 3 to 78/min on day 5. Tachycardia is a common response to fever and infection. The return to normal heart rate indicates resolution of infection and improved systemic status.
B. Temperature decreased from 38.6°C (101.5°F) to 37.1°C (98.9°F). Afebrile status reflects infection resolution and successful antibiotic response.
C. Fundus descended from 1 cm above umbilicus (day 3) to 4 cm below umbilicus (day 5). Normal uterine involution should occur at about 1 cm/day; this finding confirms proper healing and uterine contraction.
D. WBC count decreased from 33,000/mm³ to 10,000/mm³, which is within the normal range (5,000–10,000/mm³). This indicates infection control and resolution of systemic inflammation.
E. Lochia changed from dark brown and foul-smelling to small amount of brownish-red lochia without odor. The progression and normalization of lochia color and odor indicate healing and resolution of uterine infection.
F. Hemoglobin (Hgb) decreased from 11.1 g/dL to 10 g/dL, indicating continued mild anemia likely related to blood loss from delivery or infection recovery. Although the drop is slight, it does not indicate clinical improvement.
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